Improving Quality Together Improving Quality Together

The Quality Improvement Guide The Quality The Improving Quality Together Edition Improvement Guide The Quality Improvement Guide brings together learning The Improving Quality Together Edition from around – and further afield - to explain how a simple set of techniques can be applied to improve the services provided by NHS Wales.

It will encourage all staff to apply these techniques and be part of introducing change to bring about improvements. This guide supports the Improving Quality Together national learning programme, which provides a common language for improvement in NHS Wales.

“Improving Quality Together has given us a shared vocabulary and understanding as a team. It gives the whole team a different dimension and a different perspective and it has really paid off for us.” – Julia Toy, Business Manager, Powys Teaching Health Board people of Wales.

If you would like to find out more about IQT, visit www.IQT.wales.nhs.uk Includes examples of IQT projects Published by 1000 Lives Improvement which is part of Public Health Wales NHS Trust 1 The 1000from Lives Plus across Quality Improvement Wales! Guide The Quality Improvement Guide

Contents

1.  Introduction 5

2.  Improving quality requires putting the 9 person at the centre of care

3. Delivering improvement through teamwork 15 and leadership

4.  Using the Model for Improvement 19

5.  Testing changes 37

6. Communicating your improvement 43

7.  Common improvement questions 47 The Quality Improvement Guide: 8. Improving Quality Together in action 51 The Improving Quality Together Edition Copyright © 2014, 1000 Lives Improvement 9.  References 59 All rights reserved. First edition: March 2014. This guide is adapted from The 1000 Lives Plus Quality Improvement Guide published in 2011, 2013. 10. Introducing Improving Quality Together 63 These materials may be photocopied for educational, not-for-profit uses, as long as the contents are not altered in any way and that 1000 Lives Improvement is named as the source of the content. These materials must not be reproduced for commercial use, or republished under any Published by 1000 Lives Improvement, 14 Cathedral Road, CF11 9LJ circumstances, without written permission from 1000 Lives Improvement. Phone: (029) 2082 7653 How to cite this publication: 1000 Lives Improvement (2014), Email: [email protected] The Quality Improvement Guide: The Improving Quality Together Edition Web: www.1000livesi.wales.nhs.uk Cardiff: 1000 Lives Improvement

2 The Quality Improvement Guide The Quality Improvement Guide 3

1 Introduction

4 The Quality Improvement Guide The Quality Improvement Guide 5 Introduction Introduction

Introduction NHS Wales has been on a journey of quality improvement for several years. We have seen great success in making patient care safer, reducing delays and wastage, and making sure services across Board

Wales offer the same level of high quality care everywhere. Bronze

However, we know there is still room for improvement. The Silver experience of people using our health services is that care is often Gold excellent, but excellence is not reliably and consistently guaranteed. This guide introduces a common language for improvement and some The quality improvement work in Wales in the last ten years has of the techniques underpinning Improving Quality Together, and which shown that those working in NHS Wales are committed to improving are explored further in the Improving Quality Together Bronze level care - we know that nobody wants to cause harm or offer poor e-learning modules. There are also case studies that show how these quality care for their patients. techniques can be applied in different settings, to encourage and equip everyone working in NHS Wales to be a catalyst for improving However, the biggest challenge has been using the right techniques care for the people of Wales. to achieve improvement. In NHS Wales we all have two roles: Doing our job and improving our The Improving Quality Together learning programme gives staff a job. Therefore, the first question we need to ask is: “How are we set of common techniques to achieve improvements in care. This going to improve things?” common and consistent approach to improving the quality of services can be used by any member of staff anywhere across NHS Wales. We need to realise that improvement usually comes through small It will also help improvements take place more quickly and changes that make a measureable difference. Quality is rarely the spread effectively throughout the country. result of learning brand new knowledge, exciting innovations or one-off changes. Instead, we need to focus on the regular and often Improving Quality Together consists of three main levels of painstaking work of providing a reliable service and continuously development with a complementary Board level. Bronze level raises trying to improve what we do (Berwick 1992 I and Berwick 1992 II). awareness of the common language for quality improvement in NHS Wales, Silver level takes that learning into application, Gold level Experience in Wales and across the world has shown that some focuses on developing coaching capability for quality improvement simple principles and techniques can increase success. Even so, across NHS Wales, and the Board level focuses on leading system- improvement will only be maintained and spread if those techniques wide quality improvement and assurance. are widely understood and shape the way that whole organisations work (Shortell, 1998).

6 The Quality Improvement Guide The Quality Improvement Guide 7 Introduction

For improvement to be maintained there must be: • Will - We must want to improve;

• Ideas - We must know what to try;

• Execution - We must know how to change.

(Berwick, 2003 and Nolan, 2007)

The Bronze level of Improving Quality Together is the ideal introduction to these themes. The Bronze level takes about two hours to complete four e-learning modules. There are also more in-depth guides called ‘How to Improve’ and ‘Leading the Way to Safety and Quality Improvement’ which are available from 1000 Lives Improvement.

Instructions on how to complete the Bronze level of Improving Quality Together can be found at www.IQT.wales.nhs.uk. 2 Improving quality requires putting the person at the centre of care

8 The Quality Improvement Guide The Quality Improvement Guide 9 Improving quality requires putting the person at the centre of care Improving quality requires putting the person at the centre of care

Improving quality requires putting the • Person-centered - care that is respectful of and responsive to individual patient preferences, needs and values, and ensuring person at the centre of care that patient values guide all clinical decisions. The people we care for should be at the heart of all that we do. Our • Safety - avoiding harm to staff and patients from the care that starting point should always be what is best for the person is intended to help them. as a whole. • Effective - care based on scientific knowledge to all who could benefit and refraining from actions to those not likely to Analysing the real life experiences of people in your care helps to benefit. determine what individuals want and expect from their care. Patients are not outsiders to the healthcare system. In many ways, they are • Timely - reducing waits and harmful delays for both those who the only true ‘insiders’. They are the ones who experience healthcare receive and those who give care. most personally – the reliability of the system and effectiveness • Efficient - avoiding waste, of equipment, supplies, ideas, of treatment can literally be a matter of life or death to a patient and energy. (Davies, 2012). • Equitable - care that does not vary in quality because of The Institute of Medicine includes person-centred care as one of the personal ccharacteristics such as gender, ethnicity, geographic location, and socio-economic status. six domains which constitute quality in healthcare (National Research Council, 2001): Evidence shows that person-centred care can lead to improved quality, reduced waste, a better experience of care, and better Six domains of quality in healthcare use of resources.

10 The Quality Improvement Guide The Quality Improvement Guide 11 Improving quality requires putting the person at the centre of care Improving quality requires putting the person at the centre of care

There are a number of definitions of person-centred healthcare How to achieve person-centred care available from across the globe and they all have common themes: Shared decision making • Users identifying areas that need to change. The majority of individuals want to play an active role in their • Involvement in decision making and respect for patients’ treatment decision. Shared decision making tools are designed to preferences. support patients during consultations when presented with different • Empathy, dignity, compassion and emotional support. treatment options. Option grids are developed to support such treatment choices and encourage an equal partnership with those we • Clear, comprehensible and timely communication. care for. • Fast and smooth access to optimal care. • Education and empowerment to manage their conditions Provide dignified care and care for themselves. Dignity in care is at the heart of caring for people. It allows everyone to effectively engage in their care as partners and is a cornerstone A genuine partnership between the public and healthcare to person-centred care. Simple things such as supporting individuals professionals must exist to design and deliver true person-centred to set their own daily goals and helping them achieve simple tasks care. To achieve this, staff need to view the services being delivered can have a big impact in their healthcare experience. This has been through ‘the patients’ eyes’, in order to meet their needs in the ways achieved in Wales through the use of simple questions, such as ‘What most valuable to them. can I do for you today?’

Three simple questions that are helpful in achieving person-centred care are: Communicate effectively 1. What does the person need/want? Effective sharing of information is key to achieving person-centred care and can reduce demand on the system. Avoiding medical jargon 2. What is important to the person as the initial need for a service and using effective communication skills can ensure individuals are arises? more able to access and navigate the system, and better manage 3. What is important for the person following their last contact with their health. Communication techniques and tools are available to the service? support healthcare professionals and members of the public to work together more effectively.

12 The Quality Improvement Guide The Quality Improvement Guide 13 Delivering improvement through teamwork and leadership Delivering improvement through teamwork and leadership

Stories for improvement Capturing healthcare experiences are proving an effective and powerful way of making sure the improvement of services is centred on the needs of the people using them. All experiences are valuable and can provide great insight into the care provided.

Individuals are interviewed and their stories are analysed and used in numerous ways – as a tool to identify areas of good practice or improvement, to support spread of evidence based interventions, to support effective communication, and to help all staff members to appreciate the impact of the care provided. 3 Delivering improvement through teamwork and leadership

14 The Quality Improvement Guide The Quality Improvement Guide 15 Delivering improvement through teamwork and leadership Delivering improvement through teamwork and leadership

Delivering improvement through Improving Quality Together focuses on enabling frontline teams to make the improvements they see are needed every day. Combine this teamwork and leadership with a co-ordinated effort to tackle the larger scale issues, through To achieve improvement across a whole organisation there needs to teamwork and strong leadership, and a common approach be strong teamwork and leadership. One person working alone or to improvement, and large scale issues can be resolved. groups of people working in an uncoordinated way will not achieve it. Once priorities have been agreed, setting up the teams to lead on As Brent James, from Intermountain Healthcare notes, a mature taking improvement actions will help build commitment, generate quality system uses both breakthrough and incremental improvement ideas, and co-ordinate tasks, as well as review progress. We need at the same time (James B, 2012): to consider four different aspects when putting a team together: • Leadership at an organisational level (Sponsor). • Clinical or technical expertise. • Frontline leadership.

A mature quality system • Patients or customers of the process.

• Combines breakthrough and incremental improvement at the same time Identifying issues Leaders at all levels need to encourage and spread ideas about Breakthrough incremental alternative ways of doing things. Generating new ideas from frontline with incremental alone staff is particularly important. Teams should meet regularly to generate new ideas through: Breakthrough alone • Brainstorming exercises. Performance • Adapting strategies from other industries. Time • Adapting ‘best practices’ from other services or conferences. • Identifying trends by analysing patients’ stories, incidents and near misses, or ‘customer’ complaints.

• Visiting the sites of other services.

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Regularly involve new people in these meetings, including the ‘customers’ of the process, whether they are patients or other staff groups, and make sure the group is open to new views. New members of the group help to generate some of the best ideas, and students in particular can bring a fresh pair of eyes to an issue.

Asking teams to describe their perfect day, and then identify all those things that get in the way of them achieving it every day, often highlights the inefficiencies in the system that are getting in the way of teams delivering their service. This quickly involves staff in finding solutions for issues they are most concerned about changing.

Successfully introducing improvement Achieving and embedding improvement will require consistently applying a range of improvement initiatives into the daily work of the organisation. By involving all staff in making improvements, it will become the way we do things here, as opposed to top down initiatives which are very often unsustainable.

By developing driver diagrams with your teams, you can demonstrate how small changes can have a big impact, and where their improvement efforts at a local level are connected to the wider organisational aims and priorities.

The next chapter outlines the common approach to quality improvement for NHS Wales, and explores how driver diagrams can break down large scale aims into smaller improvement efforts. 4 Using the Model for Improvement

18 The Quality Improvement Guide The Quality Improvement Guide 19 Using the Model for Improvement Using the Model for Improvement

Using the Model for Improvement The second section focuses on testing these changes and for this we use a small scale cycle of change called PDSA – Plan, Do, Study, Act. For every journey we make, we need some way to guide that journey, a compass if you like, that will provide us with direction. Figure 1 The Model for Improvement A roadmap can give us a sense of where we are going, a sense of (Institute for Healthcare Improvement) where we are currently, but in addition we need to consider how we are going to get there, and whether we are making progress.

In NHS Wales our roadmap and compass for improvement is called the Model for Improvement. It was developed by Associates in Process Improvement (www.apiweb.org) in 1996, and is structured around two main sections:

The first section, framed as 3 questions, provides us with direction; our current position against that direction; and lastly an idea of how we are going to get there:

1. What are we trying to accomplish? This is the AIM and provides direction.

2. How will we know that a change is an improvement? These are the MEASURES and describe our current and future position.

3. What changes can we make that will result in an improvement? These are the CHANGES that tell us how we are going to get there.

For further details about the Plan-Do-Study-Act cycles, see page 40.

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1. What are we trying to accomplish? 2. How will we know that a change is So if we unpack each of these questions in turn, how do we shape our an improvement? aim? What is our direction? When we are clear about our desired outcome, the next task is to We need to be clear about what we are trying to accomplish – is choose a standard to measure the outcome against. What will show the aim to reduce death, avoid dependency or illness, reduce risk, us how we are progressing towards our outcome? What is our current reduce interruptions? position?

We also need to think in terms of specifics – you may be familiar with • Improvement cannot happen without measurement. the SMART objectives acronym, or you may have heard Don Berwick • We cannot try a solution until we understand the problem. who led the 100,000 Lives campaign in America who stated that • We cannot test a solution unless we are measuring its effect. ‘some was not a number, and soon was not a time’. Langley et al. (1996) suggests including these specifics in your aim: How we measure • A worthwhile topic – does it map to the domains of quality in As you test your changes, you need to be able to see whether those healthcare? changes have made a difference. • Outcome focused – what is the overall outcome, not just the process? The only way to look at this is by collecting data over time and looking at it in these terms, avoiding averages and keeping it as real • Measurable – if you can’t measure it, how are you going to time as possible. know you’ve improved? The diagram on the next page, ‘The seven steps to measurement’, • Specific population – scale it, so you are looking at one group of patients/customers, one setting etc. illustrates the complete process. The first three steps have been covered in earlier sections of this guide. • Clear timelines – by when? Steps 4 to 6 make up the ‘Collect-Analyse-Review’ cycle. First • Succinct but clear – you may be able to understand it, but test collect some information (step 4), then analyse it and present it in it with colleagues from other teams, departments and patients/ customers, do they understand it? an appropriate way to convert it into useful information (step 5), and finally review the information to see what decisions need to be made Unless we are specific, how are we ever going to know that we have (step 6). The Collect-Analyse-Review cycle then starts all over again achieved it? (step 7).

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Often the information needed is not currently being collected. If so, Figure 2: The Seven Steps to Measurement start collecting your information straight away. But we do not have to wait to start making small changes. They will not affect the overall The seven steps to take are: situation while creating the baseline.

Step 1 - Decide your aim Using ‘run charts’ is a simple way to present and analyse information Step 2 - Choose your measures over time. A more sophisticated presentation is the statistical process Step 3 - Define your measures control chart which will help you understand the scale of variation in the process you want to improve. ‘Plotting the dots’ is very effective Step 4 - Collect your baseline data because it helps us to spot trends and patterns displayed to us. Step 5 - Analyse and present your data The frequency of measurement, often carried out weekly, is a major difference between measurement for improvement and more Step 6 - Meet to decide what it is telling you traditional forms of measurement. Step 7 - Repeat steps 4 to 6 each Traditionally, figures are smoothed out to get to ‘the real underlying month or more frequently trend’ by taking an average of the period. The problem comes when comparing the previous average with the current one to see if there’s been an improvement. Simply comparing two numbers and knowing that one will be bigger than the other gives a 50 per cent chance of being better (or worse)! In contrast, run charts and statistical The first Collect-Analyse-Review cycle will provide a ‘baseline’ of process control charts have rules which provide confidence that when current performance (the starting part). If we collect data about a change has been spotted, it really is one. We give an example run 20 – 25 times and plot the results on a chart, this will provide an chart at the end of this section. ideal number of points to create a baseline or identify a trend. One way to get more points is to measure more frequently. More Finally, step 6 reminds us that it is vital to set time aside to look frequent measurement allows for faster feedback on whether your at what the measures are telling us. How often the information changes have made an improvement and more opportunities to make is collected, analysed and reviewed sets the pace for change decisions about what to do next. For this reason some have referred being introduced. to the rate of measurement as the ‘heartbeat’ of your improvement.

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When we are aiming to improve, it is important that measurement Example of using a run chart is carried out fairly and openly. However, if people think that their A stroke unit has developed a new process for referring patients measurement will be used to criticise them, then they will be for CT scans, along with staff training to communicate the changes reluctant to collect and share that information. in process. The aim of the work was to improve the percentage of Frequent measures also allow us to monitor reliability – how many patients which receive a CT scan within 24 hours of admission. times did we do what we intended as a proportion of the total The stroke unit has data for the period June 2009 to May 2011. number of tries? For example, if we have a procedure for screening The data for June 2009 – June 2010 is a baseline position prior to all patients admitted to , what proportion of the total were any service improvement work undertaken: actually screened? Improving outcomes however relies on more than just screening. We have to take action based on the results, we have Figure 5 Percentage of patients who have to intervene. Now we need both of these two steps to be reliable CT scan within 24 hours of admission to get our outcome. When we try to do two things in a process, 100 90 reliability gets harder. What proportion of those screened received 80 the resulting intervention? If both steps have 80 per cent reliability, 70 Referral process changed 60 the reliability of the process is 64 per cent 50 40 (80 per cent of 80 per cent). 30 Average 20 Typically, when we measure reliability for the first time, the results 10 are disappointing. 80 per cent is typical for a one step process, and Percentage 0 less than 50 per cent for bundles of steps where four or more steps Jun10 Jul 10 Jul 09 Oct 10 Oct 09 Apr 11 Apr 10 Jan 11 Jan 10 Sep 10 Sep 09 Feb 11 Feb Feb 10 Feb Mar 11 Mar 10 Jun 09 Aug 10 Aug 09 Dec 10 Dec 09 Nov 10 Nov 09 May 11 May 10 are linked. Figure 6 Percentage of patients who have It is often possible to reach 95 per cent reliability for single steps (for CT scan within 24 hours of admission example, by providing training, memory aids and built-in reminders). 100 90 If greater levels of reliability are needed, or if these simple changes 80 do not deliver 95 per cent, the system itself needs to be redesigned. 70 60 Design is the best tool for achieving reliability. 50 40 30 Average 20 10 Percentage 0 Jun10 Jul 10 Jul 09 Oct 10 Oct 09 Apr 11 Apr 10 Jan 11 Jan 10 Sep 10 Sep 09 Feb 11 Feb Feb 10 Feb Mar 11 Mar 10 Jun 09 Aug 10 Aug 09 Dec 10 Dec 09 Nov 10 Nov 09 May 11 May 10

The sample data displayed in this run chart is for illustration purposes only.

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To monitor the impact of changes in process we need to calculate An example of different types of variation the median average baseline position. The median (15 per cent) has Every day I drive to work. It normally takes me about 55 minutes, been calculated for the baseline period. This is shown as a dotted red if there are no unusual occurrences, but this does vary. It rarely line on the charts. In the first chart it is projected beyond June 2010, takes exactly the same time to drive to work due to levels of traffic, when the service improvement work commenced. The median shows weather, or the timing of traffic signals. These time differences are that in half of the months at least 15 per cent of patients received a expected. It is common cause variation. CT scan within 24 hours. If everything remained the same this would not change. One day, there was an accident on the motorway. My journey to work took 94 minutes. This is special cause variation. If this happened to In July 2010, the staff training commenced and a new referral you, would change your route to work every other day just because process was introduced. The second chart demonstrates the impact of this single occurrence? of the changes in process. There has been a “shift” in the data. A shift in the data is represented by six or more consecutive data A few days later road works began on the motorway. The journey to points above the median line. work now took 75 minutes. For the next few days it took around 75 minutes as well. It looks like this new drive time would continue, so I Once we have established there have been any changes in the decided to look for a different route. data using run chart rules, and we fully understand what changes have impacted on the data we are able to recalculate the median This data can be quickly articulated in a run chart, which helps to review for any future changes in the data. The second chart identify the type of variation occurring. demonstrates a new median of 65 per cent. Now 65 out of 100 patients typically receive a CT scan within 24 hours.

Making the right decision based on data Variation is the natural fluctuation that we see in our processes. For example, the percentage of patients receiving their CT within 24 hours is not constant from one month to the next as we saw in the previous example.

Understanding variation is vital when deciding how to improve our processes and services. There are two different types of variation, “common cause” variation and “special cause” variation.

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Driving to work - road works Type of Variation Recommended Action Suggested tool

100 Common Cause Understand the process Process map 90 so that changes 80 introduced will change

70 the process

60 56.5 Special Cause Investigate the Root cause

50 occurrence and analysis Time

40 determine what factor external to the process 30 has caused the variation 20

10 In our work we often react to special cause variation, and look to 0

1 3 5 7 9 redesign the system around these one-off events, as opposed to 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 Days looking at what is underlying the common cause variation.

You can see the drive to work is usually around 55 minutes and the accident leads to the journey of 94 minutes. Using a run chart like this quickly shows that this is special cause variation by how different that data point is to the rest. The journey times then revert back to having common cause variation around 55 minutes for a further six data points, i.e. six days.

Then the journey time increases due to the road works. The data in the run chart shows that this has caused a ‘process shift’ to a resulting drive time of around 75 minutes. At this point it makes sense to look for a different route to work.

In the workplace, when we have a process that is producing unsatisfactory results, understanding whether we are seeing common or special cause variation is vital when deciding our method on addressing the issue.

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3. What change can we make that will Driver diagrams and the Model for Improvement result in improvement? A driver diagram represents the key interventions which will help us achieve our aim. If we reflect back on the Model for Improvement, a Once we have a clear aim, and a baseline, it is only at this stage that driver diagram turns our Model on its side: we identify what changes we can test to accomplish our aim.

Consider these elements when looking at what changes to test: Driver diagram and the Model for Improvement

What isn’t working a. Feedback from patients, staff and other services around you will help you see what isn’t working. b. What change will give the biggest benefit? c. How much of what we are doing is repeated work, or work that could have been done right first time? d. What can be made simpler? Ask your patients and the staff that use your service. e. Are there evidence-based interventions not happening for every Secondary patient? Change driver Process mapping is a great tool to help teams identify where they Primary Secondary Change can make changes, as it allows them to form a team view on how the driver driver process is really working and how it should work in the future. Aim. Secondary Change An improved driver system What should we be doing We use driver diagrams to summarise the desired outcomes of a Secondary service and how they can be achieved. Primary driver driver If we create a driver diagram in a balanced way and we reliably do Secondary the actions that it suggests, then we can be confident we will reach driver our aim.

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When producing driver diagrams there are some basic rules which Two examples on the following pages show how this can be used must be followed: for both non-clinical and clinical areas, and how the drivers can be

• The first column – ‘Aim’ – shows the desired outcome of the separated into theme or time-related elements: service (the simpler the better).

• The second column – ‘Drivers’ – shows the factors that affect An example of a driver diagram that might be used in road safety the outcome. Aim Drivers Interventions • The third column – ‘Interventions’ – this name can confuse, but it shows the actions that have been shown to be integral to a service and make a difference. Clear road markings Clear road signs A driver diagram should be as brief and simple as possible. In Safe roads Safe road layout most cases there will be three columns, but larger aims may Re-design accident blackspots have secondary and even tertiary drivers. As far as possible, the interventions should state what should happen within a service but not specify where it takes place or the type of staff involved. A driver Safe MOT Testing diagram should be seen as a working document. vehicles Manufacturing Standards Driver diagrams help you to think of the change or problem in context and can prompt you for factors that you might have forgotten or ignored. They also show the linkage between the interventions you Skills and knowledge test Reduce Testing for over 80’s Competent plan to make and your aim. death Medical grounds for not and safe and injury on driving drivers When relevant to a service, evidence-based interventions should be UK roads Alcohol testing included in your driver diagram, while remembering to be brief and Drug testing Speed and signal traps concentrate on the things that will improve the outcomes of your service the greatest.

There is a large amount of literature available on achieving change Competent Television advertising pedestrians In-school training and we have deliberately kept this text short. However, Pronovost Well-designed crossings provides another very accessible approach for medical settings (Pronovost et al, 2008). Effective Fast ambulance response Think of the essential points that will make a difference to your aim response to Paramedic training – look at your process map if you have one – what points are key to accidents Air ambulance available delivery? This will help you identify your drivers.

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An example of a driver diagram for improved outcomes after a stroke

Rapid diognosis using Rapid a recognised tool recognition (for example ROSIER) of symptoms Diagnosis confirmed by and diagnosis experienced clinician (within 3 hours)

CT Scan. Admission to stroke unit. Check ability to swallow. Nutritional screening. Emergency Prescription of regular treatment for aspirin (If non- people with haemorrhagic stroke) stroke (within 24 hours) 72 hours physiological Improve the monitoring. Assessment outcomes of manual handling. for people Specialist medical following a Getting review. Physiotherapy stroke the patient assessment started. mobilised Getting patients out following stroke of bed (within 3 days)

Occupational Therapy assessment started. Full screening and Specialist care appropriate assessment after a stroke of remaining problems. (within seven Multi-disciplinary team days) goals set. Information shared with patients and careers in an appropriate format. Estimated discharge dates discussed with patients and careers 5 Testing changes

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Testing changes Human factors – smarter ways of working The aviation industry has long been aware that 70-80% of aviation Once we have identified the changes we wish to test that will affect accidents can be attributed to human rather than mechanical error our Aim, we use the PDSA cycle approach to test these changes. (Endsley, 1988). With other ‘safety critical’ industries, aviation has However, before we start testing our changes, there are some human developed the principles of human factors which work to counter the factors we need to take into account. natural human propensity to error. Innovations which have taken the human factor into account are all around you: the three pin plug – impossible to plug-in any other way; diesel pumps – impossible to now Human error put diesel into many modern petrol cars, as the pumps are different A central principle of healthcare improvement work is that harm sizes; cash points, which now give you your card back before your and waste are not caused by bad people but instead by bad systems. money, and beep to remind you it’s there. Contrary to the perceived image of harm in healthcare caused by When you are considering your tests of change, check them malice or intentional negligence on the part of the individual, it is against the following list of principles from the WHO Patient Safety errors of omission that are responsible for most healthcare-related Curriculum Guide for Medical Schools (World Health adverse events. Organization, 2009): One large study has demonstrated that the rate at which basic, • Avoid reliance on memory. standard care was not delivered in US healthcare was 45% (McGlynn • Make things visible. et al, 2003) indicating that it was what we don’t do as healthcare teams that causes harm and avoidable mortality. These frequent • Review and simplify processes. lapses are not a sign of poor personal standards or of a lack • Standardise common processes and procedures. of knowledge or skills. They are an inevitable consequence of • Routinely use checklists. attempting to perform in a complex system with human limitations. • Decrease the reliance on vigilance. As the phrase has it, ‘to err is human’, and whilst human beings are capable of brilliant and innovative solutions to problems, maintaining Teams have used human factors principles to improve communication reliability in our processes and practices in the often chaotic by adopting safety briefings and using the SBAR (Situation, healthcare environment under conditions of stress and fatigue make Background, Assessment, and Recommendation) tool in verbal and it inevitable that error will occur. printed format in settings from the board report to escalating care for the deteriorating patient.

The PSAG (Patient Safety at a Glance) board promotes situational awareness for the entire clinical team whilst performing a debrief

38 The Quality Improvement Guide The Quality Improvement Guide 39 Testing changes Testing changes and allows teams to celebrate what went well during a shift or Plan clinical incident whilst planning on how to improve performance Plan what you are going to do differently – ‘who, what, where and next time. when’. NHS Wales Awards winners 2013, Hywel Dda University Health Board utilised the human factors principles in their redesign of the signage Do in Withybush Hospital with their service users. Carry out the plan and collect information on what worked well and what issues need tackling. Taking these elements into account can make our processes less complex, more reliable and therefore safer. Study Gather relevant team members as soon as possible after the test for a short informal meeting. Analyse the information gathered and Plan, Do, Study, Act review the aim of the new procedure or technique against what Once we have designed our tests of change, taking into account the actually happened. Questions that need to be asked include the human factors, we need to test them on a small scale, with one following. person, one setting, one service provider, which is measureable in real-time and gives us quick feedback as to whether the change has ‘What is the information telling us?’ made an improvement. This approach helps ensure sustainability too. ‘What worked and what didn’t work?’ ‘What should be adopted, adapted, or abandoned?’ Even if something has been shown to work in other settings, we should take the time to do a small-scale trial. There are almost no Act ‘plug and play’ solutions that work in all situations. Testing allows us Use this new knowledge to plan the next test. Agree the changes and to adapt actions to particular settings. To test a new procedure or amend the outcome measures if necessary. technique, we need to ‘plan, do, study and act’ as explained below. We plan, we do it, we study it, and then we act on those results. We change our plan based on what the results have shown us, and then we start another PDSA cycle to re-test. It’s important to understand how our tests of change have impacted on our measures. Here is an example of a number of PDSAs marked on a chart recording compliance with a bundle of interventions known here as the ‘Response bundle’:

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% Compliance with Response bundle

100% Integration of RRAILS & 90% Dashboard Pilot of a new data gathering tool data entered into the dashboard 80%

70% NEWS PDSA - Training sessions on introduced 60% the ward

50% PDSA - Data collection 40% tool amended PDSA-Response bundle data unreliable 30% Safety briefing introduced 20%

10%

0 Dec 10 Jan 11 Feb 11 Mar 11 Apr 11 May 11 Jun 11 Jul 11 Aug 11 Sep 11 Oct 11 Nov 11 Dec 11

October 2011 - No patients on the ward identified as being at risk of deterioration in the 24 hour period

The team can clearly see where tests of change have had an impact, and where they have not, what may need re-tweaking, and what can be expanded.

We should continue testing in this way, refining the new procedure or technique, until it is ready to be fully introduced. But, do it quickly (think in days, not weeks). When the change has been reliable for 90 to 95 per cent of patients it can be spread to more sites.

Don’t assume that a change can simply be ‘rolled out’ once it has been successfully tested. The introduction needs to be managed at every stage. There is no hard and fast rule for how fast to introduce 6 the change. Once it has been introduced in a new area, test the Communicating your change again. improvement

42 The Quality Improvement Guide The Quality Improvement Guide 43 Communicating your improvement Communicating your improvement

Communicating your improvement Talking to frontline staff to hear their views, thoughts and successes with the improvement will encourage others to get involved. Every Good communication supports every part of an improvement attempt should be made to gather information on the progress and programme as it aims to involve people, introduce new ideas, achievements of frontline staff, and to communicate this widely. procedures and techniques, and change culture. It is important to provide resources for others to spread the message. An effective communications strategy reinforces improvement These could include template articles and press releases, logos and work by: images, presentations and video material (along with advice on how • Developing language which wins ‘hearts and minds’. to use them). • Communicating the improvements and the involvement of those When improvement continues over a significant period of time, the delivering them. real challenge is how to maintain interest. We need to resist the • Developing tools which allow people – both frontline staff and temptation to change the messages and approach to ‘freshen things leaders – to understand what needs to be done. up’. The focus should stay on the aim of the work, those who are delivering the changes, and the differences those changes • Conveying involvement and success. are making. • Creating a co-ordinated ‘joined up’ approach which gives energy, maintains momentum and makes sure new ways of working are spread throughout and across organisations.

To present information in ways which will be understood and encourage involvement we need to identify audiences and the perspectives they bring. For example, taking the time to ask and understand what motivates frontline staff is essential for shaping all communications with them (Welsh NHS Confederation, 2009).

Focus groups can be a useful way of uncovering issues that may encourage or detract from the improvement. The results can then be used to develop communication objectives and important messages.

A well-crafted key message conveys the focus of the work in a short but memorable statement, reflecting the values and hopes of those who are involved. This is part of developing a ‘hearts and minds’ approach, which involves people on a practical and an emotional level.

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7 Common improvement questions

46 The Quality Improvement Guide The Quality Improvement Guide 47 Common improvement questions Common improvement questions

Common improvement questions must be transformed into a culture that emphasises integration and teamwork rather than individualism, measurement for improvement Is audit helpful? rather than judgement, and continuous learning from each other Many staff take part in clinical audits as part of professional practice. rather than identification of “best practices” which are treated as Audits are essentially about comparing what should be happening sacred cows”. with what has actually happened. This means that it is useful for governance and assurance, for example, in whether service standards or expected practice has been followed. Do care pathways and national service However, audits only provide a ‘snapshot’, which usually relies on an frameworks drive change? interpretation of notes or records originally compiled for a different These are both useful devices for agreeing models of service and purpose. At its best, an audit gives detailed knowledge of a process setting out expectations for service users. But on their own, they and can be helpful in setting improvement priorities. are unlikely to drive change. The reasons why were described by Greenhalgh (2004) who researched the characteristics of effective Even when an audit results in specific recommendations for changes. They are as follows: improvement, and a commitment is given to carry out another audit at a later date, too often the necessary change does not follow. • ‘It must have clear relative advantage’ – the people or teams (users) who are asked to make the change part of their work How does the Model for Improvement differ must be able to see that the new method is likely to be better. from traditional change methods? • ‘It must have compatibility with the users’ values and ways of The Model for Improvement requires the ongoing gathering of working’ – if users find it hard to incorporate the new method, they are unlikely to do so. information and feedback, rather than periodically assessing progress. Improvement science encourages teams to know their • ‘Complexity must be minimised.’ systems and work to achieve better outcomes. If we know our • ‘Users will adopt more readily if innovations allow trialability’ system, and know where it is failing, we can choose and adapt an – can it be tested on a small scale to allow learning and improvement idea from elsewhere (Greenhalgh, 2004). Rolling out familiarity before full commitment? best practice reinforces the opposite – ‘top-down’ instructions which • ‘There must be observability, that is, it must be seen to deliver impose solutions that do not take account of the actual problem and benefit’ - if the benefits are not obvious, or they take a long which then cannot be assessed. time coming, energy will be lost. As Shortell (1998) said: “The overall system of caring for patients • ‘Reinvention is the propensity for local adaptation’ – this is the key to achieving sustainable improvement. A good improvement must be incorporated into the changing system and not preserved like a museum piece.

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What is available to help me make an improvement? The Improving Quality Together learning programme provides staff with the skills and support to make the improvements they see are needed every day.

Each NHS Wales organisation has an IQT lead who can direct you to the relevant level of development to meet your needs.

Contact details and extra resources can be found on the IQT website: www.IQT.wales.nhs.uk

8 Improving Quality Together in action

50 The Quality Improvement Guide The Quality Improvement Guide 51 Improving Quality Together in action Improving Quality Together in action

Improving Quality Together in action Aneurin Bevan University Health Board: Cleaner operating theatres lead to safer care. Every NHS Wales organisation is taking part in Improving Nurse Helen Dinham used the skills she learnt to reduce surgical Quality Together. site infections by improving the standard practice of cleaning in orthopaedic theatres in the health board. ABM University Health Board: Improving patient flow and communication on hospital Improving Quality Together helped her team address the obstacles wards. that were preventing the correct level of cleaning taking place such as standardising equipment and amended policies. Reducing delays in a patient’s journey and improving communication The outcome of the project was 100 per cent compliance with the on hospital wards are just two of the key benefits gained from Jo cleaning requirements, meaning infection risks were reduced and Rowland’s silver project in the Princess of Wales Hospital, Bridgend. patients would recover more quickly. The Assistant Head of Physiotherapy used her Improving Quality She said: “Reaching our target was very good for staff morale and Together training to implement daily board rounds to discuss each has reassured patients that the quality of care and the standard patient and find out the next step needed. of cleanliness in orthopaedic theatres is excellent.” Reporting back findings on a daily basis has increased efficiency and resulted in reduced lengths of stay in hospital and improved patient flow through the wards. Betsi Cadwaladr University Health Board: It has also provided a consistent approach which has improved Improving mouth care for patients. communication between staff, and between staff, patients and Practice Development Nurse, Suzie Wilson used her Improving Quality their families. Together silver training to improve the mouth care offered by her Jo said: “Now we have a consistent, clear, sustainable approach nursing colleagues to patients in hospital. which has made a real difference to patients’ journeys.” She knew from patient satisfaction surveys, carried out in the health board, that high quality mouth care wasn’t given to patients all of the time.

Issues included patients not being encouraged to continue with their normal mouth hygiene routines and the need to improve the cleaning of patients’ dentures.

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Small tests of change were implemented, beginning with one patient, Cwm Taf University Health Board: one ward, then three wards before spreading the improvement. Improving discharge procedures to reduce delays. She said, “Improving Quality Together helped to engage nurses Assistant Director of Quality Improvement and Clinical Governance, who are responsible for delivering mouth care and made them Claire Bevan has been working with teams to deliver the feel as if they were part of the solution.” organisation’s improvement priorities. The work on flow has led to changes that mean patients wait for less time before being assessed.

Cardiff and Vale University Health Board: All senior nurses have received silver training and are currently using Improving access to dental services for patients in their new skills to improve patient flow by looking at board rounds prison. and improved discharge. Head of Primary Care Service Delivery, Rhian Blake used her silver Claire has worked on a new framework for IQT that ensures it training to improve access to dental services for patients at Her becomes an integral part of day-to-day work across the health board. Majesty’s Prison in Cardiff. She said, “By learning more about what actually makes a In the past 18 months, the profile of the prison population had difference in service improvement and impact on patient outcomes and experiences we can accelerate the transformation changed significantly with more individuals on higher remand and of services.” shorter sentences.

As a result, many patients had incomplete dental treatment or didn’t receive the required treatment in a timely fashion. Hywel Dda University Health Board: Improving communication between and GP Rhian used the programme’s methodology to analyse the problem practices. and find solutions which included the immediate allocation of appointments when needed and a quicker triage process.The changes South Pembrokeshire Senior Primary Care Locality Manager Hayley led to a reduction in complaints and fewer missed appointments. Blyth is using her silver training to improve communication between secondary and primary care.

The focus is to ensure patient discharge letters are sent from the hospital to the GP who made the referral rather than just sent back to the GP practice.

She is currently halfway through her project and is already seeing an impact with improved communications, less delays in the system and more seamless care for the patient.

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She said, “Improving Quality Together is helping ensure the right said Chair, Professor Sir Mansel Aylward CB. information is going to the most appropriate person at the right “Quality has to be the priority for every member of staff – and time. By improving the process we are ensuring more timely, if the events of Mid Staffs have taught us anything, Boards must effective and seamless care for our patients.” take the lead. They need to send a clear message that they are committed to quality – and completing the first level of the programme was one way in which we could do this. Powys Teaching Health Board: Reducing interruptions and increasing efficiency. “The online training module provides an insight into basic improvement methodology which staff can apply in their work – Board Business Manager, Julia Toy used her Improving Quality whatever their role in the organisation. I’m certainly going to Together silver project to reduce staff interruptions to increase be applying the framework in my role as chair of the efficiency and improve patient care. organisation.”

She worked with the patient services team in Llandrindod Wells Hospital to encourage them to do the online training and use the Velindre NHS Trust: learning to reduce interruptions, enabling staff to focus more on the Making it easier for members of the public to patients they were treating. access training. Julia said, “Before Improving Quality Together some staff felt Training and Development Manager Zoe Whale used her silver training it was up to managers to come up with solutions and ideas. Now to make it easier for patients and the public to access important everyone understands it’s a shared responsibility. training before they take part in clinical research that is looking for “It just gives the whole team a different dimension and perspective and it really paid off for us in Powys.” better treatments for common, often life-threatening illnesses. Zoe works at the National Institute for Social Care and Health Research (NISCHR), which is part of Velindre NHS Trust, and provides Public Health Wales NHS Trust: an all Wales training programme for research. Setting the improvement agenda at board level. There were delays in getting people booked into training and when Nearly one in four members of staff in Public Health Wales have the process was analysed, they found it included 26 steps – much taken up the challenge to develop their quality improvement skills. longer than it needed to be. The team are now testing ways to This commitment is matched by the top of the organisation, with ensure patients get quicker access to training so they can contribute the entire board of the organisation completing the bronze level. to research. “I was delighted that the Public Health Wales board was the first Zoe said: “Improving Quality Together gets you thinking about in Wales to complete the Improving Quality Together what you can do. People have really welcomed being part of it. It bronze level,” will improve our services, and also develop our staff.”

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Welsh Ambulance Services NHS Trust: Referral scheme improves quality of care for patients Staff in the are using the programme to help reduce unnecessary hospital admissions and support care closer to patients’ homes.

The alternative care pathways work, which is being carried out with health boards, aims to make better use of community services for patients who have fallen or had epileptic or diabetes-related episodes.

Instead of taking them to hospital, paramedics can refer patients to their GP or an identified community team using a 24/7 internal telephone service operated by trained staff.

Since the launch of this new way of working, more than 2858 patients have been safely referred to an alternative care pathway. Unscheduled Care Lead Grayham McLean, said, “This work is ensuring patients receive the most appropriate care, from the right clinician, at the right time and in the right place.”

9 References

58 The Quality Improvement Guide The Quality Improvement Guide 59 References References

References Langley GJ, Nolan KM, Nolan TW, Norman CL, and Provost LP (1996), ‘The Improvement Guide – A Practical Approach to We referred to the following documents when producing this guide. Enhancing Organisation Performance’. San Francisco: Balestracci D (2005), ‘SPC for the real world’, Quality Digest. Jossey-Bass. com. McGlynn E.A, Asch S.M, Adams J, Keesey J, Hicks J, DeCristofaro (www.qualitydigest.com/sept05/departments/spc_guide.shtml) A, & Kerr E.A (2003) ‘The quality of healthcare delivered to adults in the United States. New England Journal of Medicine Berwick DM (2003), ‘Errors today and errors tomorrow’, New 348: pp 2635-2645 England Journal of Medicine, 348: pp 2570-2572 National Research Council (2001) Crossing the Quality Chasm: Berwick DM, Enthoven A, and Barker JP (1992), ‘Quality A New Health System for the 21st Century. Washington: The Management in the NHS: The doctor’s role – I’, British Medical National Academic Press Journal issue 304, pp 235 - 239 Nolan, TW (2007), ‘Execution of Strategic Improvement Berwick DM, Enthoven A, & Barker JP (1992), ‘Quality Initiatives to Produce System-Level Results’, IHI Innovation Series Management in the NHS: The doctor’s role – II’, British Medical White Paper, Institute for Healthcare Improvement, Cambridge, Journal issue 304, pp 304 - 308 Massachusetts (www.ihi.org) Davis, J. (2012) Person Driven Care. Cardiff: 1000 Lives Plus Pronovost P, Berenholtz S and Needham D (2008), ‘Translating Deming, WE. 1993. The new economics for industry, government, evidence into practice: a model for large scale knowledge education. Revised 2nd edition. Cambridge: MIT Press. translation’, British Medical Journal, issue 337, pp 963-965

Deming, WE. 1982. Out of the crisis. Cambridge: MIT Press. Reinertsen JL, Bisognano M, and Pugh MD (2008), ‘Seven Leadership Leverage Points for Organization-Level Improvement Endsley, M.R (1988) ‘Design and evaluation for situation in (Second Edition)’, Institute for Healthcare awareness enhancement’. Proceedings of the Human Factors Improvement, Cambridge, Massachusetts (www.ihi.org) society 32nd Annual Meeting, pp 97-101. Santa Monica: Human Sari A, Sheldon T, Cracknell A, Turnbull A, Dobson Y, Grant C, Gray Factors Society W, Richardson A (2007), ‘Extent, nature and consequences of Greenhalgh T, Robert G, Macfarlane F, Bate P, and Kyriakidou adverse events: results of a retrospective casenote review in a O (2004), ‘Diffusion of Innovations in Service Organisations: large NHS hospital’, Quality and Safety in Healthcare, issue 16, Systematic Review and Recommendations’, The Milbank pp 434 - 439 Quarterly, issue 82 (4), pp 581-629 James, B (2012) A Mature Quality System. Presentation at the IHI Forum.

60 The Quality Improvement Guide The Quality Improvement Guide 61 References References

Shortell SM, Bennett CL, and Byck GR (1998), ‘Assessing the Impact of Continuous Quality Improvement on Clinical Practice:

What It Will Take to Accelerate Progress’, Milbank Quarterly issue 76 (4), pp 593-624

Shreve J, Van Den Bos J, Gray J, Halford M, Rustagi K, Ziemkiewicz E (2010) ‘The Economic Measurement of Medical Errors’, Society of Actuaries Health Section, Milliman Inc.

Solberg L, Mosser G, and McDonald S (1997), ‘The Three Faces of Performance Measurement: Improvement, Accountability and Research’, Joint Commission Journal of Quality Improvement, issue 23 (3), pp 135 - 147

Vincent C, Neal G and Woloshynowych M (2001), ‘Adverse events in British hospitals: preliminary retrospective record review’. British Medical Journal, issue 322, pp 517-519

Welsh NHS Confederation (2009) NHS Communications: what it means, how to do it and why bother. (www.welshconfed.org)

World Health Organization (2009) Patient Safety Curriculum Guide for Medical Schools. (http://www.who.int/patientsafety/ education/curriculum/download/en/) 10 Introducing Improving Quality Together

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Introducing Improving QualityTogether

NHS Wales aims to provide What are the core skills? the highest quality and safest The core set of skills are based on the Model for Improvement, care for the people of Wales. looking at: Improving Quality Together • setting aims is a national learning • measures programme of core • understanding your system improvement skills for all NHS Wales’ staff and contractors. • identifying changes

The programme builds upon • testing those changes recognised local, national • spreading improvements and international expertise. The skills focus on a person-centred approach in all we do, using Taking part will help you play a vital part in transforming NHS Wales measurement for improvement and small tests of change to achieve into the service that people need. The programme will give you an high reliability. opportunity to develop your skills and gain accreditation in quality improvement methodology. Find out more about Improving Quality Together at www.IQT.wales.nhs.uk You will share a common and consistent approach to improving the quality of services that will help improvements take place much more quickly and spread effectively throughout the country. Improving Quality Together will: • Equip you to find new ways of working to save you time and “ I think Improving Quality Together is excellent. It gives our reduce stress. frontline staff the skill-base to go into their own departments • Help you put the people you help at the heart of everything and say ‘I can make this improvement.” – Neil you do. “Improving Quality Together has helped us get ahead of the • Help you provide an even better service. curve.” – Colleen “IQT gets you thinking about what you can do. People have really welcomed being part of it. It will improve our services, but also develop our staff.” – Zoe

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